Steerable endoluminal punch

ABSTRACT

A steerable transseptal punch system and method of using the steerable transseptal punch system to access the left atrium.

This application is a continuation of U.S. application Ser. No.13/750,689, filed Jan. 25, 2013, now U.S. Pat. No. 8,961,550, whichclaims priority to U.S. Provisional Application 61/663,517, filed Jun.22, 2012 and U.S. Provisional Application 61/625,503, filed Apr. 17,2012, both of which are hereby incorporated by reference in theirentirety.

FIELD OF THE INVENTION

The invention relates to transseptal punches.

BACKGROUND OF THE INVENTION

Defects in the left atrium are common, and cause a variety of ailments,including atrial fibrillation, mitral valve prolapse, and atrialappendage thrombosis. These defects can be treated with minimallyinvasive procedures, with catheters inserted into the atrium. The leftatrium must be approached from the right atrium, with cathetersnavigated through the vena cava and through the fossa ovalis, which is athin wall between the right and left atrium. The fossa ovalis must bepunctured to allow passage of catheters into the left atrium. Topuncture the fossa ovalis, surgeons use a transseptal punch, which isalso referred to as a Brockenbrough needle. The Brockenbrough needle isa long, very slender punch which is curved at its distal end. Thiscurvature is important as it facilitates operation of the punch.

In a typical procedure in which access to the left atrium is obtainedtransseptally through the right atrium, a surgeon delivers a Mullinsguide catheter into the right atrium, and then delivers a transseptalpunch through the Mullins guide catheter to the right atrium. Thetransseptal punch (and usually an integral obturator or dilator) isnavigated through the Mullins guide catheter with a stylet disposedwithin the punch. At this point the distal tip of the transseptal punchis disposed within the distal end of the Mullins guide catheter. Afterconfirming that the punch is properly located and oriented, the surgeonthen withdraws the stylet completely, and withdraws the Mullins guidecatheter a short distance to expose the tip of the transseptal needle,and then pushes the transseptal punch through the fossa ovalis. Afterthe transseptal punch has pierced the fossa ovalis and entered the leftatrium, the surgeon pushes the Mullins guide catheter over the punch sothat the distal tip of the Mullins guide catheter resided in the leftatrium. The surgeon then removes the punch entirely from the Mullinsguide catheter. After the Mullins guide catheter tip is disposed withinthe left atrium, the surgeon can deliver any desirable catheter ordevice to the left atrium through the Mullins guide catheter.

The transseptal punch, which is curved, is forced through the generallystraight Mullins guide catheter. This may result in skiving or carvingof small slivers of plastic from the inside of the Mullins catheter. Anyslivers of plastic scraped from the catheter may be deposited in theright or left atrium, and subsequently cause injury to the patient.

SUMMARY OF THE INVENTIONS

The devices and methods described below provide for a robust steeringmechanism for a steerable Brockenbrough needle, or transseptal punch.The transseptal punch comprises two tubes, one disposed within theother. The inner tube extends a short distance beyond the distal tip ofthe outer tube to provide the penetrating tip of the punch. The outertube has a region of enhanced flexibility at its distal end, whichestablishes a deflectable or “steerable” segment. The inner tube isfixed to the outer tube at a point just distal to the deflectablesegment. The inner tube, in a region corresponding to the deflectablesegment, is split by a longitudinally extending slot. The deflectablesegment can be forced to bend by pulling the inner tube proximallyrelative to the outer tube, (or pushing the outer tube relative to theinner tube). The longitudinally oriented slot in the inner tube providesflexibility needed for deflection, while preventing collapse of theouter tube. A proximal hub, which is fixed to both the inner tube andthe outer tube, is operable to pull the inner tube distally relative tothe outer tube (or push the outer tube relative to the inner tube). Useof the steerable transseptal punch avoids the skiving problems of priorart transseptal punches.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a side view of a transseptal punch assembled so thatthe inner tube is bent in a direction 180 degrees opposite that of theouter tube, resulting in a substantially straight punch configuration.

FIG. 2 illustrates a side, partial breakaway, view of an outer tube ofan articulating transseptal punch comprising a plurality of slots nearthe distal end to generate a region of increased flexibility.

FIG. 3 illustrates a side, partial breakaway, view of an inner tube ofan articulating transseptal punch comprising a longitudinal slotdividing the tube into two axially oriented parts which are connected atthe distal end of the inner tube.

FIG. 4 illustrates a partial breakaway view of the distal end of thearticulating transseptal punch comprising the outer tube and the innertube arranged concentrically and oriented circumferentially.

FIG. 5 illustrates a side view of the distal end of the articulatingtransseptal punch incorporating the inner split tube and the outerT-slotted tube with the inner tube being pulled proximally relative tothe outer tube causing the outer tube to deform into a curve having verystiff, or rigid, mechanical properties.

FIG. 6 illustrates the distal end of an articulating septal punchadvanced nearly to the distal end of an obturator or dilator, which iscoaxially, removably assembled into the central lumen of a guidecatheter sheath.

FIG. 7 illustrates the distal end of an articulating transseptal punchfurther comprising a removable obturator having a collapsible distalshield.

FIG. 8 illustrates a cross-sectional view of the proximal end of thearticulating transseptal punch comprising a stopcock and a bendadjusting mechanism.

FIG. 9 illustrates an oblique view of the proximal end of thearticulating transseptal punch.

FIG. 10 illustrates an outer tube cut in its flexible regions withshorter lateral slots and with reduced or complete elimination of someT-slots near the proximal end of the flexible region to improveresistance to bending in that region.

FIG. 11 illustrates an inner tube wherein the disconnected side has beenremoved, leaving only the connected side and the distal end.

FIG. 12 illustrates a cross-sectional view of a tubing configuration ina steerable transseptal punch within the flexible region, wherein theseparation slot in the inner tube is substantially at the midpoint orcenter of the inner tubing.

FIG. 13 illustrates a lateral cross-section of a tubing configuration ofa steerable transseptal punch within the flexible distal region, with anoff-center separation slot.

FIG. 14 illustrates a top view of a portion of the distal flexibleregion of an outer tube comprising dovetails or interlocking grooves toincrease torsional resistance to torque or side-to-side motion.

FIG. 15 illustrates a side view of a portion of the distal flexibleregion of an outer tube comprising dovetails or locking grooves toreduce torsional bending or side-to-side motion.

FIGS. 16 through 20 illustrate the use of the steerable transseptalpunch in establishing access to the left atrium of the heart from theright atrium.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 illustrates a side view of a punch, needle, or catheter assembly1, with an integral articulating or bending mechanism which functions tobend the distal end of the punch. The punch assembly 1 comprises aninner tube 2, an outer tube 3, a stylet or obturator wire 4, anobturator grasping tab 5, a stopcock 6, an inner tube pointer 7, anouter tube pointer 8, an inner tube hub 9, and an outer tube hub 10. Thedistal end of the inner tube 2 is sharpened to serve as needle or apunch adapted to pierce the fossa ovalis. The stylet or obturator wire 4is affixed to the obturator grasping tab 5. The stylet or obturator wire4 is inserted through the central lumen of the inner tube 2 and isslidably disposed therein.

FIG. 2 illustrates a side view, in partial breakaway, of the distal endof the axially elongate outer tube 3, which has distal flexible portion11, and a proximal, less flexible portion 12. The distal flexibleportion is formed by a snake-cut portion 13 with a plurality of lateralor radial slots 14 cut into the tube, and a plurality of longitudinalslots 15 intersecting each radial slot on either side of the outer tube.The plurality of radial slots 14 serve to render the region of the outertube 3 in which the radial slots 14 are located more flexible than theproximal region 12 which is not slotted. (The flexible portion may berendered flexible, relative to the less flexible portion, by any meanswhich weakens a length of the tube, which may include numerouslongitudinal slots, piercings, a thinner wall thickness, etc. as well asthe snake cuts depicted.) The plurality of longitudinal “T” cuts, serveto further render the region of the outer tube 3, in which the “T” cuts15 reside, more flexible than in tubes where such “T” cuts 15 were notpresent. The longitudinal “T” cuts 15 are optional but are beneficial inincreasing the flexibility of the outer tube 3 in the selected bendregion. The radial slots 14 can be spaced apart by about 0.02 to about1.0 inches with a preferred range of about 0.1 inches to about 0.8inches and a further preferred range of about 0.15 inches to about 0.5inches. The spacing between the partial lateral slots 14 can vary. Thespacing between the radial slots toward the proximal end of the outertube 3 can be about 0.3 inches while those radial slots 14 nearer thedistal end of the outer tube 3 can be spaced about 0.15 inches apart.The spacing can change in a step function, it can change graduallymoving from one end of the outer tube 3 to the other, or it can increaseand decrease one or more times to generate certain specific flexibilitycharacteristics. Increased spacing increases the minimum radius ofcurvature achievable by compression of the radial slots 14 whiledecreased spacing allows for a smaller minimum radius of curvature.

The number of radial slots 14 or, optionally, the number of radial slots14 with longitudinal T-cuts 15 can number between about four and about50 with a preferred number being between about six and about 25 and amore preferred number of about eight to about fifteen. As illustrated inFIG. 2, there are 12 radial slots 14, each modified with a “T” slot 15.The radial slots 14 can be shaped differently. For example, the radialslots 14 can be at angles other than 90 degrees to the longitudinalaxis, curved, V-shaped, Z-shaped, W-shaped or the like. In otherembodiments, the ‘T’ slots 15 can have, for example, further cutsapproximately lateral to the longitudinal axis, along any portion of the“T” cut 15. In yet other embodiments, the distal flexible portion 11 cancomprise a region of coil, helix or spring which can further comprise abackbone on one side.

The outer tube 3 can have an outer diameter of about 0.020 to about 0.1inches with a preferred outside diameter of about 0.040 to about 0.060inches and a more preferred diameter of about 0.045 inches to about0.055 inches. In the illustrated embodiment, the outside diameter isabout 0.048 inches while the inner diameter is about 0.036 inches. Theinside diameter of the outer tube 3 can range from about 0.0.010 inchesto about 0.090 inches.

FIG. 3 illustrates the distal end of an axially elongate inner tube 2.The inner tube has a lumen running from the proximal end of the tube tothe distal end of the tube, and comprises a proximal, uncut portion 16(which, when assembled within the outer tube will reside within theproximal uncut region 12 of the outer tube), and a flexible regionformed by a longitudinal slot 17. The slotted region is characterized byan angled lead-in slot 18, a pendent partial cylinder 19, a partialcylinder 20, and a distal uncut tip of the inner tube 21. The distal tip21 interconnects the free side partial cylinder 19 and the partialcylinder 20, such that the partial cylinder 19 is attached to theremainder of the inner tube at its distal end. The connected side is ahalf-cylinder 20 spanning the intact proximal portion and the intacttube of the distal tip. The free side is a partial cylinder, pendentfrom the intact tube of the distal tip (though it could be pendent fromthe intact tube of the proximal portion), radially opposed to thepartial cylinder 20. As described below, the pendent partial cylinderserves to limit the radial collapse of outer tube flexible portionduring bending of the assembled punch, while the long slot provides theflexibility needed to allow deflection of the outer tube. The partialcylinder 19 and the partial cylinder 20 are most conveniently formed bycutting a slot in the inner tube, but can also be affixed to each otherby welding, adhesives, fasteners, or the like.

The lead in 18 to the longitudinal slot 17 is beneficially angled toprevent guidewires, stylets, or other catheters, which are insertedthrough the central lumen from being caught or bumping against an edge.The angled lead in 18 serves as a guide to assist with traverse of astylet, obturator, or guidewire past the lead in 18 and into the distalregion of the steerable transseptal needle. The lead in 18 can be angledfrom between about −80 degrees (the angle can be retrograde) from thelongitudinal axis (fully lateral) to about +2 degrees and preferablyfrom about +5 degrees to about +20 degrees with a most preferred angleof about +8 degrees and about +15 degrees. In the illustratedembodiment, the angle of the lead in slot 18 is about 10 degrees fromthe longitudinal axis. A second feature of the lead in 18 is that it ispositioned or located proximally to the most proximal “T” slot 15 in theouter tube 3 when the two tubes 3, 2 are affixed to each other (see FIG.4). The lead in 18 may be located at least 1-cm proximal to the proximalmost “T” slot 15 and preferably at least 2-cm proximal to the proximalmost “T” slot 15 so that bending in the distal region does not distortthe lead in 18 and cause kinking, misalignment, or pinching of theinternal lumen.

The inner tube 2 can have an outside diameter that is slightly smallerthan the inside diameter of the outer tube 3 so that the inner tube 2can be constrained to move longitudinally or axially within the outertube 3 in a smooth fashion with relatively little force exerted. In theillustrated embodiment, the outside diameter of the inner tube 2 isabout 0.033 inches giving about a 0.0015 inch radial clearance betweenthe two tubes 3 and 2. The inside diameter of the inner tube 2 can rangefrom about 0.002 to about 0.015 inches less than the outside diameter ofthe inner tube 2. In the illustrated embodiment, the wall thickness ofthe inner tube is about 0.006 inches so the inside diameter of the innertube is about 0.021 inches. The lumen of the inner tube 2 can be sizedto slidably accept a stylet or obturator, as shown in FIG. 1. A typicalstylet wire can range in diameter from about 0.01 to about 0.23 incheswith a preferred diameter range of about 0.012 to about 0.021 inches. Inanother embodiment, the outer tube 3 has an outside diameter of about0.050 inches and an inside diameter of about 0.038 inches. In thisembodiment, the inner tube 2 has an outside diameter of about 0.036inches and an inside diameter of about 0.023 inches. The radial wallclearance between the inner tube 3 and the outer tube 2 is about 0.001inches and the diametric clearance is about 0.002 inches.

The inner tube 2 transmits force along its proximal non-slotted region12 from the proximal end of the inner tube 2 to the lead in 18 where theforce continues to be propagated along the connected side 20 to thedistal end 21. The outer tube 3 transmits force along its proximalnon-slotted region 12. Longitudinal forces applied to the distal,flexible region with the slots 14 cause deformation of the outer tube inan asymmetrical fashion with the side of the outer tube 3 comprising thepartial lateral slots 14 forming an outer curve if the slots 14 areexpanded and an inside curve if the slots 14 are compressed. Forces tocause bending are preferably exerted such that the partial lateral slots14 are compressed up to the point where the gap closes, but no further,however forces can also be exerted to expand the slots 14, howeverlimits on curvature are not in place because the lateral slots 14 canopen in an unrestrained fashion except for the material properties ofthe outer tube 3.

The disconnected side 19 of the inner tube 2, separated from theconnected side 20 by the longitudinal slot 17 and the lead in 18, servesto maintain an undistorted tube geometry and provide resistance todeformation while helping to maintain the inner lumen in a roundconfiguration and provide a shoehorn or funnel effect to guide aguidewire, or stylet therethrough as they are advanced distally. Thedisconnected side 19, being separated from the force transmitting member12 cannot provide any substantial longitudinal load bearing structure,although at its distal end, where it is integral or affixed to thedistal end 21, some tension load carrying capability exists. The innertube 2 can be considered a split tube and does not carry a load incompression or tension along substantially the entire length of thependent side 19.

The radial slot 14 and the T-Slot 15 in the outer tube 3, as well as thelongitudinal slot 17 in the inner tube 2, and the lead in slot 18 can befabricated by methods such as, but not limited to, electron dischargemachining (EDM), wire EDM, photoetching, etching, laser cutting,conventional milling, or the like. Different slot configurations canalso be employed, such as curved slots, complex slots, zig-zag slots, orthe like. The partial lateral slot 14 can be configured with a tongueand groove or dovetail design to prevent or minimize lateral movement ortorquing of the outer tube 3 in the flexible region. The tongue andgroove or dovetail (not shown) can be generally centered between two “T”slots, for example. The parts can be ganged such that, using wire EDM,for example, a plurality of tubes can be cut to reduce manufacturingcosts. As many as 20 to 30 tubes, or more, can be fixtured, secured, andetched by the aforementioned methods.

FIG. 4 illustrates a side view of the distal end 22 of an articulatingtransseptal punch. The distal end 22 comprises the outer tubing 3further comprising the radial slots 14 and the inner tube 2 furthercomprising the longitudinal slit 17 and the distal tip 21. A weld 23affixes the distal end of the outer tubing 3 to the connected side 20 ofthe inner tube. This weld is preferably a ring weld circumscribingsubstantially the entire circumference of inner tube. The outer tube 3and the inner tube 2 are rotationally oriented about the longitudinalaxis such that the connected side 20 of the inner tube 2 is generallyaligned with, and affixed or welded at weld 23 to the outer tubing 3 onthe side comprising the partial lateral slits 14. In other words, theslots and the connected side are circumferentially aligned, meaning thatthey are positioned at or near the same line along the circumference ofthe tubes. Weld 23 may be spot weld, which fixes only a small portion ofthe circumference of the outer tube to a corresponding small portion ofthe circumference of the inner tube. In this case, the slots and thefixation point between the outer tube and the inner tube arecircumferentially aligned, meaning that they are positioned at or nearthe same point along the circumference of the tubes. The width of thepartial lateral slits 14, the T-slots 15, and the longitudinal slot 17can range from about 0.001 to about 0.050 inches with a preferred rangeof about 0.005 to about 0.020 inches. In the device shown in FIG. 4,adapted for use as a transseptal punch to be used within a Mullinscatheter, the slits 14, 15, and 17 are about 0.010 inches. The width ofthe partial lateral slits 14 on the outer tube 3 can be used, incompression to provide at least some limit to how much the outer tube 3can bend in compression along the side comprising the partial lateralslits 14. Note that the distal end of the inner tube 2 extends beyondthe distal end of the outer tube 3. The inner tube 2 extends about 10 mmto about 20 mm or more beyond the distal end of the outer tube 3. Thedistal end 22 can further comprise one or more separate radiopaquemarkers 24. This construction provides for reduced device complexity,increased reliability of operation, and reduced manufacturing costsrelative to other steerable devices. The system also provides for highstiffness when the distal end 22 is straight, as illustrated, curved asin FIG. 5, or curved, bent, deflected, steered, or otherwise deformed inany configuration between straight and maximally curved. Thearticulating transseptal punch is necessarily stiff, has high columnstrength, and has significant resistance to bending from externalsources because it needs to force an incision through tissue at the endof a very long, 2 to 4 foot length, of very small diameter punch tubing.Thus, the all-metal tubing punch can translate forces from its proximalend to its distal end that a substantially polymeric catheter could notcome close to equaling. Catheters carrying such a punch would be lesseffective for the specific purpose of transseptal puncturing than wouldthe articulating transseptal needle.

The distal end 22 of the articulating transseptal punch is generallyfabricated from metals with sufficient radiopacity or radio-densenessthat they are clearly visible under fluoroscopic or X-ray imaging.However, if this is not the case, additional radiopaque markers 24 canbe affixed to the outer tube 3, the inner tube 2, or both. Theseradiopaque markers can comprise materials such as, but not limited to,tantalum, gold, platinum, platinum iridium, barium or bismuth compounds,or the like.

Close tolerances between the internal diameter of the outer tube 3 andthe outside diameter of the inner tube 2, ranging from a radial gap ofbetween about 0.0005 inches to about 0.008 inches, depending ondiameter, cause the two tubes 3 and 2 to work together to remainsubstantially round in cross-section and not be ovalized, bent, kinked,or otherwise deformed. The two tubes 3 and 2 can be fabricated from thesame materials or the materials can be different for each tube 3, 2.Materials suitable for tube fabrication include, but are not limited to,stainless steel, nitinol, cobalt nickel alloy, titanium, and the like.Certain very stiff polymers may also be suitable for fabricating thetubes 3, 2 including, but not limited to, polyester, polyimide,polyamide, polyether ether ketone (PEEK), and the like. The relationshipbetween the inner tube 2, the outer tube 3, and the slots 14, 15, 17, 18serve to allow flexibility and shaping in high modulus materials such asthose listed above, which are not normally suitable for flexibility. Theinternal and external surface finishes on these tubes 3, 2 arepreferably polished or very smooth to reduce sliding friction betweenthe two tubes 3, 2 because of their very small cross-sections and theirrelatively long lengths. Lubricants such as, but not limited to,silicone oil, hydrophilic hydrogels, hydrophilic polyurethane materials,PFA, FEP, or polytetrafluoroethylene (PTFE) coatings can be applied tothe inner diameter of the outer tube 3, the outer diameter of the innertube 2, or both, to decrease sliding friction to facilitate longitudinalrelative travel between the two tubes which is necessary forarticulating the flexible, slotted region near the distal end 22 of thearticulating transseptal sheath. The exterior surface of the outer tube3 can be covered with a polymeric layer, either substantiallyelastomeric or not, which can cover the slots 14, 15, etc. and present asmoother exterior surface to the environment. The exterior surface canbe affixed or configured to slip or slide over the exterior of the outertube 3.

The inner tube 2 may be split lengthwise in the flexible region, and aportion, or the entirety, of the distal end of the inner tube 2 can beaffixed to the outer tube 3 and functionality can be retained. Thedistal end 21 of the inner tube 2 can, in some embodiments, be retainedso as to create a cylindrical distal region 21 in the inner tube 2 andthis entire cylindrical distal region 21, or a portion thereof that doesnot project distally of the distal end of the outer tube 3 can be weldedto the outer tube 3 around a portion, or the entirety of thecircumference of the outer tube 3. If only a portion of the inner tube 2is welded to the outer tube 3, then the weld is beneficially located,approximately centered, on the side of the outer tube 3 comprising thepartial lateral slots 14. The cylindrical distal region 21 is abeneficial construction, rather than completely cutting the inner tube 2away on one side, since the distal region 21 projects distally of thedistal end of the outer tube 3 to form the tip of the punch furthercomprising a sharpened tip 25 configured to punch through myocardialtissue (refer to FIGS. 11 and 13).

FIG. 5 illustrates the distal end 22 of the articulating transseptalneedle in a curved configuration. This view shows the distal end 22, theouter tube 3, the inner tube 2, the outer tube lumen 11, the distal endof the proximal region of outer tube 12, the distal end 21 of the innertube 2 the sharpened distal tip 25, the plurality of outer tubelongitudinal cuts or slots 15, and the plurality of outer tube partiallateral cuts 14. The outer tube partial lateral cuts 14 provide spacesthat close up when the side of the tube in which the lateral cuts 14 arelocated is placed in compression. Such compression is generated bypushing the outer tube 3 distally relative to the inner tube 2, or,conversely, pulling the inner tube proximally relative to the outertube, through operation a proximally located translating mechanism. Whenthe gaps of the partial lateral cuts 14 close, further compression ismuch more difficult because the outer tube 3 stiffens substantially whenno further gap exists for compression. The composite structure, with theinner tube 2 nested concentrically inside the outer tube 3, isrelatively stiff and resistant to kinking no matter what amount ofcurvature is being generated. Such stiffness is essential when using thearticulating transseptal needle to deflect another catheter such as aMullins introducer, or other guide catheter.

Preferred radius of curvatures for the distal end can range from about 1inch to about 6 inches, with a preferred range of about 2 inches toabout 4 inches and a more preferred range of about 2.5 to about 3.5inches for the purpose of puncturing the atrial septum. Even smallerradius of curvatures would be appropriate in, for example, thecerebrovasculature, the arteries of the heart, and the like. The radiusof curvature need not be constant. The proximal end of the flexibleregion can have the partial lateral cuts spaced more widely than thoseat the distal end of the flexible region, causing the distal end to bendinto a tighter radius than, the proximal end of the flexible region. Inother embodiments, the distal region can be less flexible than theproximal end of the flexible region.

The partial lateral cuts 14, and the “T”-slots in the outer tube 3 arebeneficially treated using etching, electropolishing, passivation,sanding, deburring, machining, or other process to round the externaledges of the partial lateral cuts 14. Thus, the edges are blunted orrounded so they are not sharp such as to cause the articulatingtransseptal needle to dig, skive, or shave material from the inside of apolymer guide catheter since that is a benefit of using the articulatingtransseptal needle rather than a pre-curved, non-articulating,transseptal needle or other punch that, when advanced distally through apolymeric sheath, can scrape or skive material from the inner diameterof the sheath or introducer.

The distal end 25 is preferably sharp, but it can also be somewhat orcompletely blunted. In the case of partially or completely blunteddistal construction, the distal end can be operably connected to asource of electrical or radiofrequency (RF) energy and puncture holescan be created using the electrical or RF energy. The energy is carriedby the inner tube 2, which is preferably electrically insulated from theouter tube 3, from the hub 49 into which electrical or RF energy can beapplied to the distal tip 25.

FIGS. 6 and 7 illustrate the distal end 22 of the articulatingtransseptal punch advanced through a central lumen 36 of a dilator orobturator 37, which in turn is disposed within a Mullins guide catheter38. The distal end 22 comprises the outer tube 3, comprising theplurality of partial lateral cuts 14, and the inner tube 2, comprising asharpened distal tip 25. The sharpened distal tip 25 comprises a bevel39, one or more facets 40, a point 41, and a rounded or blunted outsideedge 42. The obturator 37 further comprises the central lumen 36. Theguide catheter 38 further comprises a central lumen 43. The guidecatheter 38 and its obturator 37 are generally curved near the distalend. When the distal end 22 of the transseptal punch is advanceddistally through the lumen 36 of the obturator 37, scraping of the innerwall of the obturator 37 is prevented by inclusion of a rounded edge 42of the distal end 25 toward the outside of the curvature. The distalsharp end 25 comprises a bevel 39 to create a sharpened tissue punchwith a point 41. As illustrated, the point 41 of the bevel is radiallyaligned with the side of the punch with the slots 14 and the pendentpartial cylinder 19. The facets 40 are optional but can be provided innumbers ranging from one to about 10. The bevel 39 can be generated at asingle angle, or with a complex curvature. In some embodiments, thebevel 39 can be generated at an angle of about 20 to about 80 degreesfrom lateral to the axis of the tube with a preferred range of about 30to about 60 degrees from lateral, and a most preferred range of about 40to about 50 degrees. The point 41 can be a point in three dimensions orin two dimensions, such as the point 41 illustrated herein.

FIG. 7 illustrates the distal end 22 of an articulating transseptalpunch further comprising a stylet 4. The stylet comprises the core wire44, a proximal lock and grasping tab 5 (shown in FIG. 1), aself-expanding basket 45, and the rounded distal tip 46. The basket isconstrained in a small diameter configuration when withdrawn into theinner tube 2, and expands resiliently or pseudoelastically to a largediameter configuration when pushed distally out of the inner tube. Thelarge diameter configuration has a diameter large enough to block thesharp distal tip of the inner tube from scraping against the inner wallof the obturator 37 or guide catheter 38. With the basket formed on thedistal end of the stylet, the stylet 4 acts as a shield to assist withblunting the sharpened distal end. The stylet 4 can be fabricated frommaterials such as, but not limited to, stainless steel, nitinol, cobaltnickel alloy, titanium, and the like using methods such as cold rollingor tempering to achieve substantial spring conditions. The collapsingshield feature 45 is created by means of a split tube of springstainless steel or pseudoelastic nitinol, comprising a plurality oflongitudinal extending struts 47 defined by longitudinally extendingslots or openings 48. The struts are biased outward to create a radiallybulging basket structure when unrestrained, which can be readilydeformed to a small diameter configuration which fits inside the lumenof the inner tube when inserted into the lumen. The slotted tube shield45 is preferably integral to the core wire 44, but may be disposed as aseparate structure over the core wire. The amount of outward bulge (theouter diameter in the large diameter, unconstrained configuration) ofthe shield 45 need not be large but must be sufficient interfere withcontact between the sharp distal tip of the inner tube and the innerwall of the surrounding catheter component. The basket in the largediameter configuration need only be larger than the inner diameter ofthe inner tube, but preferably equals or exceeds the inner diameter ofthe inner tube. The benefits of the stylet and basket, combined with thehollow Brockenbrough needle, may be obtained with or without thesteerable Brockenbrough structure described in the other figures.Additionally, the stylet can be replaced with a guide wire, withself-expanding basket disposed on the distal end of the guide wire, asdescribed in relation to the stylet. The expandable distal end of thestylet is beneficial because the relatively large wall thickness of theinner tube (about 0.004 to 0.009 inches) relative to the ID (about 0.013to 0.023 inches) may not adequately protect the sharp distal end of theinner tube from damaging the interior of a catheter, even with anon-expandable stylet in place and projecting distally therefrom. Theexpandable distal end of the stylet can be forced open and closed, ifcomprised of a non-elastic or non-superelastic material rather than aself-expanding material.

The outer tube 3 can be modified to adjust stiffness. It can bepreferential to increase the resistance to bending moving distally toproximally on the outer tube 3. This increase in bending resistancecontravenes the tendency of the outer tube to bend more severely at theproximal end of the flexible region than in the distal region. It ispossible to configure the bending so that the bend radius isapproximately constant or such that a greater curvature (smaller radiusof bending) is generated moving toward the distal end of the bendableregion. The partial lateral slots 14 can be cut with reduced depth moreproximally to increase the resistance to bending imparted by the outertube 3. The partial lateral slots 14 can be cut more narrowly in themore proximal regions to reduce the distance the slot 14 can close. TheT-slots 15 can be reduced in length or removed in the more proximalregions of the flexible region of the outer tube 3. Elastomeric bumpersor fillers can be added to some of the partial lateral slots 14 toreduce the amount the partial lateral slots 14 can compress. Once thepartial lateral slots 14, associated with the T-slots 15 have closedunder bending of the outer tube 3, further bending is resisted and issubstantially arrested. By tailoring the width and spacing of thepartial lateral slots 14, a specific final curvature can be tailored fora given catheter.

FIG. 8 illustrates a side, cross-sectional view of the hub 49 of anarticulating septal punch. The hub 49, disposed at the proximal end ofthe outer tube 2 and the inner tube 2, includes a hub body 50, astopcock petcock 51 further comprising a petcock handle 52 and a petcockthrough bore 53, a Luer lock fitting 54, an arrow pointer 55, a keyedlumen 56, a setscrew or pin 57, a jackscrew body 58 further comprising aplurality of threads 59 and a central lumen 60, a control knob 61further comprising a plurality of threads 62, a central lumen 63, theprotrusion 64, and a circumferential recess 65, an outer tube weld 66,an orientation mark 67, and an inner tube weld 68. The hub body 50 canfurther comprise a plurality of recesses or complementary structures 69.The petcock 51 is affixed to the petcock handle 52 by welding, integralfabrication, fasteners, adhesives, or the like. The petcock 51 isretained within a lateral through bore in the hub body 50, which is inthe illustrated embodiment, tapered, using a locking “C” washer,fastener, screw, pin, or the like (not shown). The petcock 51 can berotated about its longitudinal axis to align the through bore 53 withthe axis and central lumen of the hub body 50 or it can be rotatedsideways to shut off and seal the lumen against the flow of fluids. TheLuer lock 54 can be affixed to, or integrally fabricated with, the hubbody 50. The knob 61 is retained within the hub body 50 by the setscrewof pin 57 which prevents axial movement but permits rotational movementas constrained by the setscrew, projection, or pin 57 riding within thecircumferential recess 65 which is integrally formed or affixed to theknob 61. The jackscrew body 58 is capable of axial movement within thehub body 50 but is restrained from rotation about the long axis by flatsor features on the exterior of the jackscrew body 58 which areconstrained by flats or features in the keyed lumen 56. The knob 61comprises threads on its internal lumen which engage with externalthreads 62 on the jackscrew body 58. Rotation of the knob 61 thus causesthe jackscrew body 58 to move axially proximally or distally withmechanical advantage. Rotation of the knob 61 can be forced using manualaction or using a motor or other mechanism (not shown). The outer tube 3is affixed to the jackscrew body 58 by the outer tube weld 66. The innertube 2 is affixed to the hub body 50 by the inner tube weld 68. Thecentral lumen of the inner tube 2 is operably connected to a centrallumen of the hub body 50, the petcock through bore 53, and the lumen ofthe Luer fitting 54.

The knob 61 can comprise markings 67 to permit the user to visualize itsrotary or circumferential position with respect to the hub body 50.These markings 67 can comprise structures such as, but not limited to,printed alphanumeric characters (not shown), a plurality of geometricshapes such as dots, squares, or the like, or the markings can compriseraised or depressed (embossed) characters of similar configuration asdescribed for the printed markings. In an embodiment, the knob 61 cancomprise a number on each of the facets so the facets can be numberedfrom one to 6, in the illustrated embodiment. The knob markings 67 canfurther comprise raised structures, as illustrated, which can further beenhanced with contrasting colors for easy visualization.

The knob 61 can further comprise one or more complementary structuresaffixed or integral thereto, such as a plurality of protrusions 64 thatfit into detents 65 affixed or integral to the proximal end of the hubbody 50. Such protrusions extending into detents in the hub body 50 canprovide a ratcheting or clicking sound as well as providing resistanceto inadvertent movement of the knob 61 once it is rotated to the correctlocation. The knob 61, in some embodiments, can be biased toward the hubbody 50 to ensure that complementary structures such as the protrusionsand detents come into correct contact. In other embodiments, the knob 61can comprise a ratchet system to further control its rotary movementwith respect to the hub body 50. In other embodiments, the knob 61 cancomprise one or more detents (not shown) while the hub body 50 cancomprise one or more complementary protrusions (not shown). It isbeneficial that the knob 61 be moved only when required by the user andnot by accident or not when it is required to maintain its rotaryposition and, by consequence, the curvature at the distal end of thetubing. The number of ratchet locations, or low energy positions or setpoints, can range from about 2 per 360 degree rotation to about 20 witha preferred number of ratchet locations ranging from about 4 to about12.

FIG. 9 is a perspective view of the proximal steering mechanism of FIG.8, showing the steering hub 49 of the steerable transseptal needle,including components used to steer the needle. The proximal hub includesthe knob 61, the hub body 50, the arrow pointer further comprising thepointer 70, a stopcock body 71, the petcock 51, the petcock handle 52,and the Luer fitting 54. The pointed end 72 is aligned with the point ofthe bevel of the needle (and the direction of the curvature of theneedle), and provides a landmark by which the surgeon can determine theorientation of the bevel point within the Mullins catheter.

FIGS. 10 and 11 illustrate alternative embodiments for the outer tubeand inner tube. FIG. 10 illustrates an the outer tube 3 comprising thelumen 11, the proximal tube wall 12, the plurality of partial lateralslots 14, the plurality of T-slots 15, a short partial lateral slot 73,a slightly longer partial lateral slot 74, and a standard length lateralslot 14 but with a shortened T-slot 75. The most proximal partiallateral slot 73 penetrates less than the standard partial lateral slots14. The second (moving distally) partial lateral slot 74 is slightlylonger than slot 73 and therefore is more flexible in that region andrequires less force to generate bending. The third partial lateral slotcomprises the shortened T-slot 75 which reduces the ability of thetubing to bend given a constant bending force.

FIG. 11 illustrates the inner tube 2 comprising the lumen, the proximalregion 12, the connected side 20, the distal end 21, the sharpened tip25, and a beveled lead-in 76 at the proximal end of the distal end 21.The extended half-pipe region 77 extends substantially the entire lengthof the snake cut region of the outer tube, and may extend at least aslong, along the length of the device, as the snake cut region. Asillustrated, the half-pipe region starts just proximal to the snake cutregion of the outer tube, and ends distally at a point just distal tothe snake cut region and just proximal to the weld affixing the innertube to the outer tube. The open side of the half pipe region is on thesame side of the device as the T-slots of the snake cut region (that is,the open side of the half pipe region is circumferentially aligned withthe T-slots). The proximal end of the disconnected region can be moveddistally to increase the stiffness of the inner tube 2 in a specificregion, generally the most proximal part of this distal, flexibleregion.

Since, during use of the steerable transseptal needle, the needle isadvanced distally through an already placed Mullins guide catheter, itis beneficial that the straight steerable transseptal needle be capableof advancing through any curvatures in the already placed introducer,sheath, or guide catheter. Thus, in certain embodiments, the bevel isoriented such that the pointed point of the sharpened tip 25 is orientedtoward the direction of bending. In this way, the steerable transseptalneedle, when in its straight configuration, can be pushed against intothe curved region of the introducer, sheath, or guide catheter and nothave the sharp point dig into the wall of the introducer, sheath, orguide catheter. The side of the sharpened tip 25 away from the sharppoint can further be rounded somewhat to make it even more atraumaticand smooth so it can skate or sled along the curvature of theintroducer, sheath, or guide catheter without digging out any materialfrom the wall of the introducer, sheath, or guide catheter.

It is beneficial that the inner tube 2 can sustain compression togenerate bending of the outer tube 3 at the distal end back to straightafter being curved and even to bend beyond straight in the other (oropposite) direction. In order to sustain compression, it is beneficialthat the disconnected side 19 be separated from the connected side 20 ator near substantially the center or midpoint of the tubing. Depending onthe width of the slot 17 separating the disconnected side 19 from theconnected side 20, the location of the slot can be offset from themidpoint but this is dependent on the wall thickness of the inner tube 2and the angle of the slotting. In a preferred embodiment, interferenceexists between the disconnected side 19 and the connected side 20 suchthat the disconnected side and force transmitting member cannot movesubstantially inward, a situation that would have negative effects ofobstructing the lumen, restricting fluid flow therethrough, trappingstylets or other catheters that need to move longitudinally therein, orbuckling sufficiently to prevent application of longitudinal compressionforces on the connected side 20.

FIGS. 12 and 13 are cross sections of the inner tube in the splitregion. FIG. 12 a radial cross-section of an inner tube 2 nested insidean outer tube 3 and separated from the outer tube 2 by a annular, radialgap 78 in the flexible region of an articulating septal punch whereinthe inner tube 2 is separated by a split or gap 17 into twoapproximately or substantially equal parts, a connected side 20 and adisconnected side 19, approximately (or substantially) at the midline orcenterline of the cross-section.

FIG. 13 is a radial cross-section of an inner tube 2 nested inside anouter tube 3 and separated from the outer tube 22 by a annular gap 78 inthe flexible region of the punch where the inner tube 2 is separated bya split or gap 17 into two substantially unequal parts, a connected side20 and a disconnected side 19, substantially offset from the midline orcenterline of the cross-section.

The disconnected side 19 is retained in close proximity to the outertube 3 by its stiffness and its inability to deform such that the edgesof the disconnected side 19 can pass beyond the edges of the connectedside 20 and thus the two sides 20 and 19 are retained radially displacedfrom centerline. If the gap 17 were too large or either side 20, 19 weresmall enough to fit within the edges of the other side, thendisplacement of one side toward the centerline and confounding of theoff-center orientation of the connected side 20 or 19 would occurleading to buckling of the connected side 20 in compression andinability to straighten out a bent transseptal needle. Another problemmight be loss of torqueability and predictability of the direction ofbending. Both embodiments shown in FIGS. 12 and 13 maintaincircumferential and radial orientation of the inner tube connected side20 relative to the disconnected side 19 and promote high precisiondeflection of the distal tip.

In preferred embodiments, the annular gap 78 is minimized and isretained between about 0.0005 to 0.002 inches when the needle is about0.050 in outside diameter. Furthermore, the split or gap 17 should be asminimal as possible and in preferred embodiments can range from about0.002 inches to about 0.015 inches with a gap of about 0.004 to 0.010inches being most preferable.

FIGS. 14 and 15 illustrate alternative embodiments of the outer tube 3.In FIG. 14, the outer tube 3, in the region of the distal, flexiblesection, comprises a plurality of short longitudinal segments 79 joinedby dovetail joints 80 comprising dovetail tails 81 loosely fitted intodovetail gaps 82.

In FIG. 15, which is the same outer tube 3 shown in FIG. 14 viewed from90° offset from FIG. 14, the outer tube 3 in the region of the dovetailjoints, includes the partial lateral slots 83 disposed 90° radiallyoffset from the dovetails and dovetail receivers, joined with thedovetail through circumferential slots 14. The longitudinal T-slots 15are optional or they can be configured differently.

FIGS. 16 through 20 illustrate the use of the steerable transseptalpunch in establishing access to the left atrium of the heart from theright atrium. FIG. 16 a portion of a patient's heart, including theright atrium 91 and left atrium 92 and the fossa ovalis 93 whichseparates the two, along with the inferior vena cava 94 and superiorvena cava 95 initial placement of the distal end of guide catheter 38and obturator 37 in the right atrium. The distal end of guide catheteris curved to some extent, when disposed within the right atrium, and maybe slightly straightened within the confines of the vena cava and rightatrium.

FIG. 17 illustrates the initial insertion of the steerable transseptalpunch 1. The punch is pushed through the lumen of the guide catheter 38or obturator 37 until its distal tip is disposed within the distal endof the guide catheter 38 or obturator 37. During insertion, as the punchis pushed through the guide catheter 38 or obturator 37, the distal endof the punch is deflected by pulling the inner tube 2 relative to theouter tube 3 (or vice versa, or pushing the inner tube relative to theouter tube, or vice versa) to avoid or limit scraping of the sharp tipagainst the inner wall of the guide catheter 38 or obturator 37. FIG. 18illustrates the step of bending the distal end of the combined assemblyof the guide catheter 38, the obturator 37, and the transseptal punch 1.This is accomplished by bending the tip of the transseptal punch 1,again by pulling the inner tube 2 relative to the outer tube 3 byturning the knob on the proximal hub to push the outer tube 3 distallyover the inner tube 2. Deflection of the transseptal punch 1 will forcedeflection of the guide catheter 38 (and obturator 37) as well. Asillustrated, the distal tip of the assembly is bent, and the assembly isrotated, to place the tip and the outlet of the lumen of the guidecatheter 38 in apposition to the fossa ovalis. At this point, as shownin FIG. 19, the transseptal punch is pushed distally, relative to theguide catheter 38, to force the sharp tip out of the distal end of guidecatheter 38 and/or obturator 37 and through the fossa ovalis. Finally,as shown in FIG. 20, the guide catheter 38 and/or obturator 37 is pushedthrough the puncture created by the punch 1, so that the distal tip ofthe guide catheter 38 is disposed within the left atrium 92. Thetransseptal punch 1 (and obturator 37, if still in place) may now bewithdrawn proximally and removed from the guide catheter 38. The emptylumen of the guide catheter 38 can now be used to pass any desiredworking catheter into the left atrium.

Thus, the method of described in FIGS. 16 through 20 entails punching ahole in a body lumen or hollow organ wall entails a surgeon (orcardiologist) performing the preliminary steps of (1) inserting aguidewire into a patient's body lumen and routing the guidewire to alocation near a target site wherein the target site is an organ or bodylumen wall (the fossa ovalis, for example) and (2) advancing a guidecatheter over the guidewire to the target site, wherein the guidecatheter is an axially elongate structure having a proximal end, adistal end, and a lumen extending therethrough, and (3) removing theguidewire from the guide catheter. Next, the surgeon, (4) using anaxially elongate punch as described in FIGS. 1 through 15, comprising anintegral deflecting mechanism comprising deflectable region at thedistal end of the punch which itself comprises an inner tube with alongitudinally slotted region and an outer tube with a snake cut regiondisposed over the longitudinally slotted, and means for tensioning orcompressing the inner tube relative to the outer tube, inserts the punchinto the lumen of the guide catheter and routes the punch to the targetsite, wherein the punch is substantially straight and uncurved andoptionally deflecting the deflectable region as desired to negotiate anycurves in the guide catheter. With the deflectable region disposedwithin the distal end of the guide catheter, the surgeon deflects, withthe integral deflecting mechanism, the deflectable near the distal endof the punch so that the punch and surrounding guide catheter aresubstantially curved at the distal end and oriented toward and againstthe target site. This step is performed after completing the step ofinserting the axially elongate punch into the guide catheter and routingthe punch to the target site. Next, the surgeon or cardiologist advancesthe tip of the punch from the distal end of the guide catheter andpunches a hole in the body lumen or hollow organ wall with the punch,and advances the punch through the body lumen or hollow organ wall.Finally, the surgeon or cardiologist removes the punch and the integraldeflecting mechanism from the guide catheter.

The steering mechanism disclosed herein, comprising two or more nestedaxially elongate cylindrical tubes moving relative to each other onlyalong the longitudinal axis, can provide a high degree of precision,repeatability, force, column strength, torsional control, and the like,in a configuration with extremely thin walls and large inside diameter(ID) to outside diameter (OD) ratio. One of the tubes comprises partiallateral cuts or complex lateral gaps and the other tube comprising asplit running substantially the length of the flexible region. Thedisconnected side of the slit tube can be removed so that only apartially formed, connected side remains. However, in preferredembodiments, the disconnected side, which is actually retained at thedistal end, is not removed but serves to fill space within the lumen ofthe outer tube 3 to prevent kinking, improve column strength, preventlumen collapse and provide for guiding of central stylets or catheters.Prior art pull-wire steering devices require greater wall thickness,which reduces the size of the internal lumen relative to a given outsidediameter, or they do not have the same degree of precise movement at thedistal tip under control from the proximal end of the device.

However, the transseptal punch disclosed above, with the slit inner tubeand snake cut outer tube, can maintain its structure in compression andprovide precise control, and maintain a central lumen larger than anyother type of steerable transseptal punch. The resistance to bucklingoccurs even when the inner tube is slotted longitudinally because theinner tube is constrained within the outer tube using very tighttolerances that will not let the inner tube bend out of its straightorientation, even under compression.

The punch can be used to create holes in various structures in the body.It is primarily configured to serve as an articulating or variabledeflection Brockenbrough needle, for use in puncturing the fossa ovalisto gain access to the left atrium from the right atrium. However, thesteerable punch can be used for applications such as transluminal vesselanastomosis, biopsy retrieval, or creation of holes in hollow organs orlumen walls. The punch can be used in the cardio-vascular system, thepulmonary system, the gastro-intestinal system, or any other systemcomprising tubular lumens, where minimally invasive access isbeneficial. The punch can be configured to be coring or non-coring inoperation, depending on the shape of the distal end and whether anobturator or the circular hollow end of the punch is used to perform thepunching operation. The punch facilitates completion of transseptalprocedures, simplifies routing of the catheters, minimizes the chance ofembolic debris being dislodged into the patient, and improves theability of the cardiologist to orient the punch for completion of theprocedure.

As used in the description of the transseptal punch, the terms proximaland distal are used as they are used in the art of medical devices. Theterm proximal refers to locations along the long axis of the devicecloser to the user, the handle and the insertion point for the device.The term distal refers to point further from the user, the handle andinsertion point. The distal and proximal ends of the catheter may or maynot coincide with the distal and proximal portions of the patient'svasculature, where, for example, the transseptal punch is inserted intoa vein in the leg, which is distal to the heart, (the heart, being theorigin of the vasculature, is proximal to the remainder of thevasculature).

While the preferred embodiments of the devices and methods have beendescribed in reference to the environment in which they were developed,they are merely illustrative of the principles of the inventions. Theelements of the various embodiments may be incorporated into each of theother species to obtain the benefits of those elements in combinationwith such other species, and the various beneficial features may beemployed in embodiments alone or in combination with each other. Otherembodiments and configurations may be devised without departing from thespirit of the inventions and the scope of the appended claims.

We claim:
 1. A method of accessing the left atrium of the heart of apatient, from the right atrium and through the fossa ovalis of theheart, said method comprising the steps of: providing a punch forpunching a hole in the fossa ovalis, said punch characterized by adistal end and a proximal end, said punch comprising: an outer tubecharacterized by a proximal end, a distal end, and a flexible region atthe distal end, said flexible region characterized by a proximal and adistal end, wherein said flexible region is provided in a form in whichthe outer tube comprises a segment which is snake-cut with a pluralityof radially oriented slots in the wall of the outer tube, said radiallyoriented slots being substantially radially aligned along one side ofthe outer tube; and an inner tube characterized by a proximal end and adistal end, said inner tube having a flexible region near the distal endthereof and a distal tip adapted to pierce body tissue; said inner tubebeing disposed within the outer tube, extending from the proximal end ofthe outer tube to the distal end of the outer tube, and terminatingdistally beyond the distal end of the outer tube, said inner tube fixedto the outer tube at a point in the outer tube proximate the distal endof the flexible region of the outer tube; navigating a guide catheteruntil a distal end of the guide catheter is in the right atrium andproximate the fossa ovalis; pushing the punch through the guide catheteruntil the distal tip of the inner tube is within the distal end of theguide catheter; bending the distal end of the punch by tensioning theinner tube relative to the outer tube, to place the distal tip of theinner tube and the distal end of the guide catheter in apposition to thefossa ovalis; pushing the punch distally, relative to the guidecatheter, to force the distal tip out of the distal end of the guidecatheter and through the fossa ovalis to create a puncture in the fossaovalis; pushing distal end of the guide catheter through the puncturecreated by the punch, so that the distal tip of the guide catheter isdisposed within the left atrium; and withdrawing the punch from theguide catheter.
 2. The method of claim 1, wherein the flexible region isprovided in a form in which the inner tube comprises a segment of theinner tube with a longitudinally oriented slot, disposed within thesnake-cut segment of the outer tube.
 3. The method of claim 1, whereinthe flexible region is provided in a form in which the inner tubecomprises a segment of the inner tube with a half-pipe configuration,disposed within the snake-cut segment of the outer tube.
 4. The methodof claim 1, further comprising providing a radiopaque marker proximatethe distal tip of the punch.
 5. A method of accessing the left atrium ofthe heart of a patient, from the right atrium and through the fossaovalis of the heart, said method comprising the steps of: providing apunch for punching a hole in the fossa ovalis, said punch characterizedby a distal end and a proximal end, said punch comprising: an outer tubecharacterized by a proximal end, a distal end, and a flexible region atthe distal end, said flexible region characterized by a proximal and adistal end; and an inner tube characterized by a proximal end and adistal end, said inner tube having a flexible region near the distal endthereof and a distal tip adapted to pierce body tissue, wherein saidflexible region is provided in a form in which the inner tube comprisesa segment of the inner tube with a longitudinally oriented slot; saidinner tube being disposed within the outer tube, extending from theproximal end of the outer tube to the distal end of the outer tube, andterminating distally beyond the distal end of the outer tube, said innertube fixed to the outer tube at a point in the outer tube proximate thedistal end of the flexible region of the outer tube; navigating a guidecatheter until a distal end of the guide catheter is in the right atriumand proximate the fossa ovalis; pushing the punch through the guidecatheter until the distal tip of the inner tube is within the distal endof the guide catheter; bending the distal end of the punch by tensioningthe inner tube relative to the outer tube, to place the distal tip ofthe inner tube and the distal end of the guide catheter in apposition tothe fossa ovalis; pushing the punch distally, relative to the guidecatheter, to force the distal tip out of the distal end of the guidecatheter and through the fossa ovalis to create a puncture in the fossaovalis; pushing distal end of the guide catheter through the puncturecreated by the punch, so that the distal tip of the guide catheter isdisposed within the left atrium; and withdrawing the punch from theguide catheter.
 6. The method of claim 5 wherein the longitudinallyoriented slot in the inner tube divides the inner tube into two partswhich are disconnected from each other along their lengths.
 7. Themethod of claim 5, further comprising providing a radiopaque markerproximate the distal tip of the punch.
 8. A method of accessing the leftatrium of the heart of a patient, from the right atrium and through thefossa ovalis of the heart, said method comprising the steps of:providing a punch for punching a hole in the fossa ovalis, said punchcharacterized by a distal end and a proximal end, said punch comprising:an outer tube characterized by a proximal end, a distal end, and aflexible region at the distal end, said flexible region characterized bya proximal and a distal end; and an inner tube characterized by aproximal end and a distal end, said inner tube having a flexible regionnear the distal end thereof and a distal tip adapted to pierce bodytissue, wherein said flexible region is provided in a form in which theinner tube comprises a half pipe; said inner tube being disposed withinthe outer tube, extending from the proximal end of the outer tube to thedistal end of the outer tube, and terminating distally beyond the distalend of the outer tube, said inner tube fixed to the outer tube at apoint in the outer tube proximate the distal end of the flexible regionof the outer tube; navigating a guide catheter until a distal end of theguide catheter is in the right atrium and proximate the fossa ovalis;pushing the punch through the guide catheter until the distal tip of theinner tube is within the distal end of the guide catheter; bending thedistal end of the punch by tensioning the inner tube relative to theouter tube, to place the distal tip of the inner tube and the distal endof the guide catheter in apposition to the fossa ovalis; pushing thepunch distally, relative to the guide catheter, to force the distal tipout of the distal end of the guide catheter and through the fossa ovalisto create a puncture in the fossa ovalis; pushing distal end of theguide catheter through the puncture created by the punch, so that thedistal tip of the guide catheter is disposed within the left atrium; andwithdrawing the punch from the guide catheter.
 9. The method of claim 8,further comprising providing a radiopaque marker proximate the distaltip of the punch.
 10. A method of accessing the left atrium of the heartof a patient, from the right atrium and through the fossa ovalis of theheart, said method comprising the steps of: inserting a guidewire intothe patient's vasculature and routing the guidewire to a location nearthe fossa ovalis; advancing a guide catheter over the guidewire to rightatrium, proximate the fossa ovalis, wherein the guide catheter has aproximal end, a distal end, and a lumen extending therethrough; removingthe guidewire from the guide catheter; inserting an axially elongatepunch, said punch comprising an integral deflecting mechanism comprisinga deflectable region at the distal end of the punch which comprises aninner tube with a flexible region and an outer tube with a flexibleregion, with the flexible region of the outer tube disposed over theflexible region of the inner tube, and means for tensioning orcompressing the inner tube relative to the outer tube, into the lumen ofthe guide catheter and routing the punch to the fossa ovalis whereinsaid flexible region of the outer tube is provided in a form in whichthe outer tube comprises a segment which is snake-cut with a pluralityof radially oriented slots in the wall of the outer tube; maintainingthe punch substantially straight and un-curved pushing the punch throughthe guide catheter, until the deflectable region is disposed within thedistal end of the guide catheter; and deflecting, with the integraldeflecting mechanism, the deflectable region near the distal end of thepunch so that the punch and surrounding guide catheter are substantiallycurved at their respective distal ends; advancing the tip of the punchfrom the distal end of the guide catheter, and advancing the punchthrough the fossa ovalis to punch a hole in the fossa ovalis; advancingthe distal end of the guide catheter through the puncture created by thepunch, so that the distal tip of the guide catheter is disposed withinthe left atrium; and removing the punch from the guide catheter.
 11. Themethod of claim 10, wherein the flexible region of the inner tube isprovided in a form in which the inner tube comprises a segment of theinner tube with a longitudinally oriented slot, disposed within thesnake-cut segment of the outer tube.
 12. The method of claim 10, whereinthe flexible region of the inner tube is provided in a form in which theinner tube comprises a segment of the inner tube with a half-pipeconfiguration, disposed within the snake-cut segment of the outer tube.13. The method of claim 10, further comprising providing a radiopaquemarker proximate the distal tip of the punch.
 14. A method of accessingthe left atrium of the heart of a patient, from the right atrium andthrough the fossa ovalis of the heart, said method comprising the stepsof: inserting a guidewire into the patient's vasculature and routing theguidewire to a location near the fossa ovalis; advancing a guidecatheter over the guidewire to right atrium, proximate the fossa ovalis,wherein the guide catheter has a proximal end, a distal end, and a lumenextending therethrough; removing the guidewire from the guide catheter;inserting an axially elongate punch, said punch comprising an integraldeflecting mechanism comprising a deflectable region at the distal endof the punch which comprises an inner tube with a flexible region and anouter tube with a flexible region, with the flexible region of the outertube disposed over the flexible region of the inner tube, and means fortensioning or compressing the inner tube relative to the outer tube,into the lumen of the guide catheter and routing the punch to the fossaovalis wherein said flexible region of the inner tube is provided in aform in which the inner tube comprises a segment of the inner tube witha longitudinally oriented slot; maintaining the punch substantiallystraight and un-curved pushing the punch through the guide catheter,until the deflectable region is disposed within the distal end of theguide catheter; and deflecting, with the integral deflecting mechanism,the deflectable region near the distal end of the punch so that thepunch and surrounding guide catheter are substantially curved at theirrespective distal ends; advancing the tip of the punch from the distalend of the guide catheter, and advancing the punch through the fossaovalis to punch a hole in the fossa ovalis; advancing the distal end ofthe guide catheter through the puncture created by the punch, so thatthe distal tip of the guide catheter is disposed within the left atrium;and removing the punch from the guide catheter.
 15. The method of claim14 wherein the longitudinally oriented slot in the inner tube dividesthe inner tube into two parts which are disconnected from each otheralong their lengths.
 16. The method of claim 14, further comprisingproviding a radiopaque marker proximate the distal tip of the punch.